Provider Demographics
NPI:1558376434
Name:BANO, KRAIG Y (MPT CHT)
Entity Type:Individual
Prefix:MR
First Name:KRAIG
Middle Name:Y
Last Name:BANO
Suffix:
Gender:M
Credentials:MPT CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9475 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2212
Practice Address - Country:US
Practice Address - Phone:215-464-6200
Practice Address - Fax:215-464-9834
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT011023L2251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
5070-0003OtherCARE FIRST
61809102OtherCAREFIRST
1667747OtherPABS
DE1000037582Medicaid
234323000OtherIBC
1667747OtherPABS
234323000OtherIBC
P00479916Medicare PIN
023804QZYMedicare ID - Type Unspecified
DE022400A78Medicare PIN